Aesth. Plast. Surg.
27:58–62, 2003
DOI: 10.1007/s00266-002-0058-6
Forehead Lifting: The Juxtapilose Subperiosteal Approach
Ivo Pitanguy and Natale Ferreira Gontijo de Amorim
Rio de Janeiro, Brazil
Abstract. Aging in the upper face becomes more evident as
the eyebrow level descends. Sometimes this may begin at an
early age. The senior author has described a limited ap-
proach for the treatment of this aesthetic alteration. In se-
lected cases, the juxtapilose incision, placed laterally at the
margin of the anterior hairline, allows for the subperiosteal
undermining of the entire forehead and dissection of the
elements that cause the descent of the eyebrow. The pro-
cedure is safe and expedient, and permits for a controlled
repositioning of the eyebrow. In this paper, the authors
describe the juxtapilose incision and the subperiosteal ap-
proach of the forehead as a practical ancillary procedure
for correction of the aging face.
Key words: Eyebrow ptosis—Frontoglabellar wrinkles—
Forehead lifting
Facial aging is a biological phenomenon that brings
about undesirable changes, such as skin flaccidity and
marked lines of expression. As we age, skin properties
change and it loses its elasticity and tonicity. Gravity
and facial expressions contribute to the mechanical
deformation of the face. In addition to the loss of
elasticity and tonicity of the skin, other structural
changes occur, such as the reduction of the volume of
the facial bones, absorption of the adipose tissue, and
the creation of wrinkles on the lines of musculocu-
taneous insertion due to muscle dynamics [3]. Ptosis
of the eyebrow is a defining element of facial aging
and may present at an early age [1]. By identifying
these changes and their corresponding distortional
forces, we may be better able to reverse these signs of
aging.
Correspondence to I. Pitanguy, The Ivo Pitanguy Clinic,
Rua Dona Mariana, 65, Rio de Janeiro 22280-020, Brazil;
email: pitanguy@visualnet.com.br
The aging process presents a pattern of change for
the facial parameters that we have described in pre-
vious articles and that we have studied by analyzing
measurements taken from a sample of patients
[17,19]. Our work revealed that ‘‘round lifting’’ of the
vector of traction, described by the senior author, is
the technique that best corrects the physical defor-
mation of facial tissues secondary to aging [17,19,21].
In our experience, forehead lifting is indicated to
treat frontoglabellar wrinkles and frontal laxity and
can also promote the elevation and leveling of the
eyebrows in cases of unilateral or bilateral frontal
paralysis. Eyebrow ptosis, especially in its lateral
segment, constitutes the best indication for forehead
lifting. The use of the juxtapilose and bicoronal in-
cisions present more natural results than direct eye-
brow lifting through a superciliary incision [2].
Frontal region flaccidity and eyebrow ptosis may
produce the appearance of excess upper eyelid skin,
thus it requires a thorough evaluation [11,13,14,
16,18,19,21]. Regarding the indication for this pro-
cedure, elements of the upper face should be carefully
examined, including the length of the forehead, the
elasticity of the skin, the level of the anterior hairline,
and the quality and quantity of hair, as well as the
presence of pre-existing incisions. When ptosed eye-
lids are observed without a considerable laxity of the
tissues as a whole and, as is often the case, without
the presence of wrinkles or signs of muscular hyper-
trophy in the frontal region, the limited juxtapilose
incision with a subperiosteal approach is indicated
[2]. In cases of severe eyebrow ptosis with laxity of the
frontal area, especially in the older patient, the
bicoronal approach is indicated, associated with the
‘‘blocking lifting’’ technique, which avoids alterations
in anatomical landmarks in the face [2,11,13,14,
16,18].
In this paper, the authors describe the juxtapilose
incision performed on the hairline with a subperio-
steal approach, as a safe procedure that permits for a
I. Pitanguy and N.F. Gontijo de Amorim
Fig. 1. The juxtapilose incision is performed on the hairline
and the subperiosteal approach is used in the treatment of
the frontal area, with an ample undermining and blunt
dissection with a periosteal elevator.
controlled repositioning of the eyebrow. The subpe-
riosteal approach is used in the treatment of the
frontal area, with ample undermining and blunt dis-
section with a periosteal elevator to release the re-
taining ligaments in the superior orbital rim and the
temporal line (Figs. 1 and 2). The orbital ligament is a
fibrous band connecting the superficial temporal
fascia to the orbital rim, near the zygomaticofrontal
suture line. The galea aponeurotica is contiguous
with the superficial temporal fascia, and therefore this
structure is densely bonded together with the over-
lying skin. The orbital ligament tethers the lateral
eyebrow segment to the orbital rim and limits ceph-
alad movement during forehead flap transposition.
The transaction of the ligament is essential to obtain
the correction of eyebrow ptosis [6,7]. The deeper
layers of the galea aponeurotica and superficial tem-
poral fascia are bonded to the periosteum and fixed
to the bone medial to the temporal fusion line of the
skull and its continuation as the superior temporal
line. Careful subperiosteal dissection avoids the cre-
ation of a lesion on the supraorbital neurovascular
bundle and frontal nerve [2,9–11,13,14,16,18].
The limited juxtapilose subperiosteal incision has
proven useful when the patient presents with ptosis of
the eyebrow but few expression lines on the forehead
itself. This location is a short distance from the eye-
brow region and it is easily reached by subperiosteal
blunt dissection, with results that in most cases will
replace videoendoscopic approach [7,8,22]. Videoen-
doscopy has its indications according to the philos-
59
Fig. 2. The release of the orbital ligament, and of the re-
taining ligaments in the superior orbital rim and the tem-
poral line, allows the elevation of the eyebrows.
ophy and training of the surgeon and should be used
when properly indicated in specific cases [8].
Patient Population
Between 1957 and 2001 a total of 7,703 cervico-facial
rhytidiplasties have been performed at the senior
author’s private clinic. Forehead lifting was associ-
ated in 963 cases (12.5%). The majority of the pa-
tients was female (91%) and the predominant age
range was 50–59 years (41.5%) (Table 1). The fore-
head surgery was performed as an isolated procedure
or combined with other surgeries (Table 2). In the
majority of the cases of forehead lifting in which the
ptosis was severe, with considerable laxity of the tis-
sues, the procedure was performed by a bicoronal
incision (89%). In the remaining cases (11%), when
the ptosis was less pronounced, the surgery was done
through a limited juxtapilose incision and a subpe-
riosteal approach.
Method
This technique is begun by making a limited juxtap-
ilose incision on the hair line. The undermining is
subperiosteal in the whole forehead, reaching the
superior orbital rim, preserving the supraorbital
neurovascular bundle and frontal nerve. The orbital
ligament, near the zygomaticofrontal suture line, and
the periosteal attachments along the superior orbital
rim and the temporal line are released by blunt dis-
section with a periosteal elevator. Traction is exe-
cuted in a superolateral direction, elevating the
60 Forehead Lifting

Table 1. Age groups Table 2. Associated procedures

Age group (Years) Number of cases Percent Procedures Number of cases Percentage

30–39 70 7.3 Blefaroplasty 616 64

40–49 328 34.1 Rhinoplasty 125 13
50–59 400 41.5 Mentoplasty 39 4
60 and over 165 17.1 Others 366 38
Total 963 100 Single procedure 19 2

Fig. 3. A 60-year-old patient (A)

preoperatively and (B) two months
postoperatively.

eyebrow and the frontal area as a whole, and re- Discussion

secting the excess of periosteum and skin. The suture
should incorporate the galea and the periosteum to
help stabilize the transposed flap. Because the deeper
surface of the periosteum will adhere to the unyield-
ing frontal bone, the use the fibrin glue is not neces-
sary. The edges of the scalp are also approximated
with sutures. Adhesive tapes are placed and a ban-
dage is wound around the head, with enough tension
to exert a comfortable compression.
Case Studies
Figure 3 shows a 60-year-old woman who presented
with facial flaccidity, pronounced nasolabial fold,
and ptosis of the eyebrows. She underwent facial-
cervical lifting, with an upper blepharoplasty and a
forehead lift using the juxtapilose subperiosteal ap-
proach.
Figure 4 shows a 50-year-old woman who pre-
sented with facial flaccidity as well as asymmetry and
ptosis of the eyebrows. She underwent a face lift, an
upper blepharoplasty, and a forehead lift using the
juxtapilose subperiosteal approach. This allowed us
to level her eyebrows in addition to reducing the signs
of aging.
The face is frequently where people focus much of
their anxiety as they age. Regardless of a patient’s
chronological age, it is imperative that the surgeon
perform a detailed analysis of the face and each
subunit, so that imperfections can be individually
assessed and treated to best achieve a harmonic bal-
ance.
As gravity and skin laxity draw the eyebrows down
and wrinkles and rhytidis appear, an individual looks
older, even though these changes may begin at an
early age.
The surgical treatment of the frontal region is indi-
cated when there is ptosis of the eyebrow. An impor-
tant decision to be made is where to place the incisions.
Elements of the upper face are carefully examined,
including the length of the forehead, the elasticity of
the skin, the level of the anterior hairline, and the
quality and quantity of hair, as well as any pre-existing
incisions. In men it is very important to note the
presence of baldness in both the patient and his par-
ents. The selection of the type of incision depends on
the extension of the dissection to be performed and
whether it will be combined with other procedures.
The treatment of the forehead is usually associated
with a facial-cervical lifting, whose incisions may also
I. Pitanguy and N.F. Gontijo de Amorim
suffer variations, such as a transverse or oblique
temporal component, according to each case [16].
Nevertheless, basic surgical principles have stood the
test of time and should always be remembered. The
surgeon must be knowledgeable in details of surgical
technique and its variations to attain the best result
for each individual case.
Currently, the subperiosteal approach through a
juxtapilose incision is more frequently performed
than the bicoronal incision, since this limited incision
technique does not present some of the undesirable
results of the open approach, such as enlargement of
the scars, sensorial disturbances, and alopecia in the
postoperative period.
The juxtapilose incision is executed on the hair
implant line, and the undermining of the whole fore-
head area is subperiosteal, releasing the orbital liga-
ment and periosteal attachments along the orbital rim
and the temporal line. After releasing the periosteal
attachments, the traction of the periosteum becomes
more efficient to raise the eyebrows. By undermining
the periosteum in its deeper surface and from the
upper tissues, the surgeon may apply more tension on
his structure, therefore resecting less skin. The con-
trolled resection of the skin and the suture placement
in the galea and the periosteum will thus avoid the
undesirable enlargement of the scar. The galeal por-
tion of the transposed flap (with periosteum on its
deep surface) adheres to the frontal bone to provide
flap stability, so the use of fibrin glue is not necessary.
In the cases of patients with severe ptosis of the
eyebrow, especially in old people, the bicoronal in-
cision should be considered, since it allows for the
treatment of all of the elements of the aging forehead
and it hides the final scar within the hairline. The
bicoronal forehead lift is most commonly done to-
gether with a cervico-facial rhytidoplasty as a com-
bined procedure (‘‘blocking lifting’’) [2,11,13,14,
61
Fig. 4. A 50-year-old patient
(A) preoperatively and (B) seven
months postoperatively.
16,18]. Our experience shows that the direction of
traction presented in this article is the one that best
corrects the physical deformation of facial tissues
secondary to aging [17,19]. Certain situations, how-
ever, preclude the coronal incision, such as, patients
with a very long forehead or those who have had
previous surgery who will have an excessively re-
cessed hairline if the forehead is further pulled back.
In these cases, the final aspect will be displeasing and
give the patient a permanent look of surprise
[4,12,15,23].
Videoendoscopy has become an adjunct to proce-
dures such as the facelift. Endoscopic instrumenta-
tion has permitted the treatment of the brow through
minimal-access incisions and has proved useful in
selected cases. The subperiosteal dissection, com-
bined with the removal of the corrugator supercilii
and the procerus muscles and the release of the
periosteum from the temporal line of fusion, allows
the surgeon to lift the brow to the desired degree.
This technique is safe and well accepted among the
patients who are hesitant toward more extensive
surgery. However, its execution requires specific
training. A mixed technique, open in the temporal
areas and with the endoscope in the mid-frontal area,
may also be used [8,22].
There are other options for treatment depending
on the patient’s needs, such as the open resection of
part of the corrugator muscle in some cases of muscle
hypertrophy, resurfacing with a CO2 laser for treat-
ment of fine wrinkles, and dermabrasion (mechanical
peeling) for the treatment of wrinkles [11,13,14,
18,20]. Injection of botulinum toxin A is useful as
a complementary procedure in the postoperative
period. The botulinum toxin causes temporary
paralysis of striated muscles that promote eyebrow
ptosis, such as corrugator supercilli and procerus
muscles [5].
62
Conclusion
The forehead lift has evolved and became a standard
component of facial rejuvenation techniques for
repositioning the ptotic eyebrow [4,12,15,23]. The
limited juxtapilose subperiosteal, non-endoscopic,
forehead approach is an alternative technique to the
classic coronal lifting, when the patient presents with
primarily lateral eyebrow ptosis.
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